Ensuring Medicaid expansion delivers on its full potential

With Oklahoma voters approving Medicaid expansion this summer, residents can expect to see enormous economic returns and improved health outcomes in the coming years. Based on the experiences from other states, Medicaid expansion can lead to significant increases in access to health care, thousands of new jobs, and millions of dollars in additional revenue. While voting to expand Medicaid was a monumental step forward, the subsequent decisions by our elected officials and policymakers are just as important to ensure that Oklahomans get the most impact from their investment. The state’s processes moving forward with expansion will impact hundreds of thousands of Oklahomans and it’s important they get it right.

Essential workers will be significantly impacted 

Oklahoma’s essential workers will especially benefit from a thoughtful approach to expansion. Throughout the COVID-19 pandemic, workers in restaurants, retail, construction, health care, and maintenance remained on the front lines, classified as essential and forced to work. Many of these workers fall into the health care coverage gap. This means they don’t get health care coverage through their employer and they don’t make enough to qualify for premium subsidies, but they earn too much to qualify for Medicaid. When expansion is implemented by July 2021, adult Oklahomans in the coverage gap will qualify for Medicaid coverage. This will especially impact the state’s essential workers, such as food servers and restaurant workers, which represents the largest single industry among newly eligible workers. More than 15 percent of Oklahomans in the food service industry will qualify for Medicaid after expansion takes effect next year. 

Essential workers have kept this economy afloat during the pandemic and will be vital to the coming economic recovery. Like all Oklahomans, they deserve affordable, comprehensive health care. The strategies outlined below will be vital to ensuring low-income Oklahomans receive quality coverage.

Implementation must be cost-effective.

Oklahoma’s state Medicaid agency, the Oklahoma Health Care Authority (OHCA), has a long history of low-cost, efficient Medicaid administration, which benefits the state’s health and its bottom line. That’s why many are unclear about Gov. Stitt’s intention to outsource OHCA’s administration of the state’s entire Medicaid program to private managed care organizations (MCOs). It’s especially puzzling given the state’s unfortunate history with privatized managed care. In 1993, the state tasked OHCA with outsourcing and privatizing Medicaid administration. This turned out to be feasible only in urban areas, leading OHCA to develop its own program for rural areas, called SoonerCare Choice. Eventually, OHCA determined it could operate its own model for a quarter of the administrative cost — this, following years of ineffective provider retention, the need for higher provider reimbursements, and the demand from MCOs for an 18 percent rate increase., The contracted managed care program was terminated in early 2004. The Legislature tried to move to managed care for some SoonerCare enrollees in 2015, and again had to hit the brakes due to inevitable harm to providers. 

OHCA has already proven that it is capable of administering an effective Medicaid program, according to a report from Mathematica Policy Research Inc. a few years after the state ended its managed care experiment. The switch from contracted managed care to care provided by OHCA did not adversely impact member health outcomes or provider participation rates.  Additionally, it is estimated that managed care would have cost taxpayers more than OHCA’s program in the years after the switch. Oklahoma’s first managed care experiment showed that it is not feasible on a state-wide level, and OHCA has a demonstrated track record of providing high-quality care at a low cost.  

Implementation must be transparent.

Oklahomans should have ample opportunity to participate in the decision-making process, but this administration doesn’t have the best track record when it comes to transparency. When Gov. Stitt released his health care proposal that would have fundamentally changed the state’s Medicaid program, public comment meetings were cancelled and rescheduled with little notice. Due to the pandemic, they were shifted online, which resulted in technical difficulties, no opportunity for statements, and no available recordings. The current attempt to transition to managed care has been spearheaded by Gov. Stitt and OHCA CEO Kevin Corbett, without opportunities for legislative input. Besides OHCA’s recent Request for Information (RFI), there have been no official mechanisms put in place to gather input. Health care providers, legislators, and concerned citizens will likely not have an opportunity to comment on substantial agency and administrative changes. 

Given this opaque track record, it is vital that OHCA implement expansion in a way that is open and transparent. The agency should collect and listen to public input by providing accessible ways for impacted citizens to engage in the process. 

Implementation must be efficient.

Because Medicaid serves very low-income families, state officials must keep participants’ needs at the heart of all programmatic efforts. In Oklahoma, a state with very low payment error rates, officials must direct resources towards ensuring all eligible individuals are enrolled, rather than towards eliminating possible abuse, which occurs at negligible levels. Most states have seen decreases in coverage in recent years, and at least part of this decrease can be attributed to barriers associated with renewal processes and periodic eligibility checks.  Cumbersome enrollment and renewal processes, reduced outreach, and frequent eligibility reviews are harmful and can lead to denials of eligible individuals. Streamlined enrollment processes and consumer assistance systems like automated renewals and community-assister portals will help ensure that all qualifying Oklahomans can maintain coverage without disruptions. 

Adequate technological infrastructure is also vital to ensuring that implementation is successful. At the beginning of the COVID-19 pandemic, many Oklahomans had to wait weeks for unemployment benefits due to significant technical issues. While Oklahoma already has a relatively comprehensive online portal that can be used to apply for multiple types of benefits, including SoonerCare, OHCA must be working now to ensure that current systems can handle the influx of more than 200,000 new applications coming in July 2021. Oklahoma must learn from past failures and invest in high quality technological systems.

Implementation must be equitable.

Medicaid expansion presents an opportunity for Oklahoma to take significant strides towards reducing health disparities. Historically marginalized communities of color continue to face significant inequities in health outcomes. Indeed, Black and American Indian or Alaska Native communities have worse outcomes than their white counterparts in most measures of health.  Expansion will begin to address some of these inequities. 

Oklahoma should also structure expansion in a way that intentionally targets disparities. Barriers to coverage like work requirements, premiums, and excessive documentation requirements disproportionately impact Black individuals and single moms, and often lead to significant losses in coverage. Oklahoma’s Medicaid program must remain free of these ineffective practices. Other, more proactive measures should be used to ensure coverage for all communities; significant enrollment outreach, increased prevention efforts, and immunization and chronic disease management initiatives are good first steps. Strengthening efforts to connect individuals leaving incarceration with Medicaid enrollment and increasing the number of Black doctors would also go a long way towards a more equitable health care system. 

Let’s uphold the Oklahoma standard.

By passing State Question 802, Oklahoma voters showed they support comprehensive, accessible health insurance for low-income adults. Oklahoma officials owe it to taxpayers to ensure that expansion is implemented in a way that best promotes high-quality care, which will pay dividends in years to come. Both OHCA and the Legislature have the power to proactively work towards these goals. Citizens can advocate for quality implementation by attending and speaking at OHCA board meetings and medical advisory committee meetings, or by contacting their elected officials to encourage them to implement a cost-effective, high-quality health care system without cumbersome coverage barriers. This is a chance to uphold the Oklahoma standard by ensuring all Oklahomans get the care they deserve.